1972519213 NPI number — AMBER O VICK MD

Table of content: (NPI 1992318323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972519213 NPI number — AMBER O VICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VICK
Provider First Name:
AMBER
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972519213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 PETERSON PARKWAY
Provider Second Line Business Mailing Address:
AFFILIATED COMMUNITY MEDICAL CENTERS
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-354-2222
Provider Business Mailing Address Fax Number:
218-529-9120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 PETERSON PARKWAY
Provider Second Line Business Practice Location Address:
AFFILIATED COMMUNITY MEDICAL CENTERS
Provider Business Practice Location Address City Name:
NEW LONDON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-354-2222
Provider Business Practice Location Address Fax Number:
218-529-9120
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  48788 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01-25488 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 165H7HO . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00442141 . This is a "RR MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 985172000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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